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APPLICATION FOR 4VELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX Sft 304 EAST WEBER AVENUE,STOCMN,CA%M1-W <br /> (209)469-3420 <br /> NONREFUNDABLE PFRMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In T/IpOKete) <br /> APPLICATION IB HEM BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITH BAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1116.E AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION, <br /> JOB ADDRESSOR APN/�� �`� q� Cm' \'t['�C� 1 PARCEL SIZE/APER 4 \ <br /> OWNER'S NAME ADOREBB 1 y <br /> CONTRACTOR ,f.\ IN ADDREBB,V3� T\J.�(`� �4�*y UC/jk- '4U\ PHONE t A <br /> SUB CONTRACTOR ADDRESS LICi PHONE <br /> TYPE OF W MaYMP: ❑NEW WELL ❑ REPLACEMENT WELL ❑MONITORING WELL f ❑OTHER <br /> )1 C1CE <br /> yINSTALLATION WELL SYSTEM REPAIR ❑CP08SONNCjT��REPAIR [I VAPOR EXTRACTPON WELL E J ' <br /> Q,J N—❑R.PM, ".P. —1 DEPTH PUMPBET1E11,FT. FIRST WATER LEVEL O <br /> RY OF PUMP) [ <br /> ❑OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL i ❑ BOIL BORING S <br /> ❑DESTRUCTION: <br /> INTENOEO USE TYPE OF WELL CONSTRUCTION SPECINCATIONe �I <br /> ❑INDUSTIAL 11 OPEN BOTTOM { 1 LL OIA.OF WELLEXCAVATION DIA.OF CONDUCTOR CASINO <br /> fitDOMESTIC/PRIVATEGRAVEL PACKISIZE 1 V TYPE OF CAGINGMTEEUPVC DIA.OF WELL CAGING <br /> ❑PUBLIC/wNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION qz <br /> ❑IWAGATIONIAG ❑OTHER GROUT SEAL INSTALLED 6Y GROUT BRAND NAME ❑F''1 E <br /> [I [IN. 1. <br /> MONrramNO {� 1 GROUT SEAL PUMPED:❑Yw Na CONCRETE PEDESTAL BY MILLER: V. [IN.OE#TH 3 LID LOCKING CHESTER BOXISTOVE PIPE S� <br /> PROPOSED CONSTRUCTION,OWLLJNO METHOD: MUD ROTARY AIR ROTARY AVOER CASLE OTHF)i �Q <br /> I HE%BY CERTIFY THAT 1 HAVE PREPARED THIS APPUCATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PEfEORMANCE OF THE WOW(FOR WHICH <br /> THIS PERMIT IG ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPOFSATION LAWS OF CALIFORNIA.'CONTRACTOR'S HIRING OR SU"ONTRACTINO SIONATU<E CERTIFKS <br /> THE FOLLOWM: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW(FOR WHICH THIS PERMIT 18 IBSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COAFFORATRDN LAWS OF <br /> CARAORMA.' THF APPLICANT MUST CALL 24 HVULL IN ADVANCE FOR ALL NFOUMTb N/AT`t"O))4"-W21. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Breve#X _ �C\ Tt1e `�= \�- <br /> PLOT FLAN IO,—to Seele)ewle 'to <br /> 1.NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDINO THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE 04SPOM SYSTEM OR PROPOSED <br /> 2.OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3.DIMENSIONED OUTLINF.e AND LOCATION OF ALL EXISTING AND PROPOSED 6.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FFTV FT. <br /> STRUCTURES,INCLUDING COVERED AREAE SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR AOJOIMNO PROPERTY. <br /> QR: <br /> :. <br /> .. <br /> . o�� <br /> urn <br /> . <br /> d <br /> PAYMEN <br /> X996; <br /> PU@�,IC HEALTH SFRVI':C6;, ; <br /> ct4VIRONMENTAL HEALTH DI1([$Idr <br /> a <br /> �H .. : ... <br /> `� ..1 I <br /> DEPARTMENT USE ONLY <br /> App6wtbn Aeeeptad BY Deta C � <br /> 0—Inpectfon By Dete Pump ImoecUen By <br /> Ostr.ctbn krPeeBon By Dele <br /> cemmente: <br /> ACCOUNTING ONLY: AID# FACT <br /> PE CODES F AMOUNT REMITTEb i1FC' A:A1H RECEIVED 6Y DATE P@MTMERVICE REQUEST NUMBER INVOICE <br />